The prevalence of post traumatic and associated factors among nurses during COVID_19 pandemics: a systematic review and meta-analysis

Background Despite the negative outcomes, exposure to a crisis may cause people to experience positive changes. This study aims to analyze the prevalence of post-traumatic growth (PTG) and its relevant factors among nurses during the COVID-19 pandemic. Method The research protocol was registered with PROSPERO (CRD42022329671), and PRISMA steps were taken in this study. PubMed, Scopus and ProQuest were explored on 1/9/2022 to create the research database. According to the inclusion criterion, all studies analyzing the prevalence of post-traumatic growth through the PTG Inventory were considered eligible. They were all qualitatively assessed through the modified version of the Quality Assessment Checklist for prevalence studies. Results A total of 15 papers met the inclusion criterion (n = 22756). According to the research results, the prevalence of PTG was randomly calculated ES [95% Conf. Interval = 0.15 [0.12–0.17]), and heterogeneity was reported I2 = 98.52% (P = 0.000). The results also indicated that the mean score of PTGI decreased in nurses as their work experience and mean age increased. However, the effect was not statistically significant for the mean age (P = 0.06). According to the results, the PTGI score decreased in nurses with more work experience, a finding which was statistically significant (P = 0.04). Conclusion This meta-analysis determined a 15% prevalence rate of PTG in nurses. Psychological interventions should be developed and applied to older nurses with more work experience in order to mitigate the harm caused by the pandemic and its consequent crises.


Background
The spread of a pandemic can often lead to a series of psychological problems in addition to physical complications [1].Although such pandemics impact different parts of society, some people are more vulnerable than others due to their greater exposure to crises [2].Nurses are at the frontier in this realm.In fact, since the outbreak of the COVID-19 pandemic, nursing services and relevant problems have frequently been discussed worldwide.The nurses involved in the COVID-19 cases are very susceptible to adverse psychological problems [3].Due to exposure to traumatic situations, these nurses may experience negative psychological outcomes such as post-traumatic stress disorder (PTSD) [4], sleep problems [5], burnout [6], exhaustion [7], hopelessness [8], anger and depression [9].
However, not all nurses who experience and encounter a pandemic show such maladaptive responses.In addition to these negative outcomes, work-related traumatic events may lead to positive changes in nurses, something which is known as post-traumatic growth [10,11].
Although, experiencing a traumatic event can shatter key elements of a person's worldview, beliefs, and goals and create a high level of psychological distress [12], but the study of the texts of different religions, the works of ancient philosophers, scientists of other fields, and also new researches show that the pain and suffering caused by negative experiences can lead to positive changes in different people and societies [13].
Proposed by Tedeschi and Calhoun, post-traumatic growth (PTG) is a concept defined as "positive psychological changes experienced as a result of coping with extremely challenging circumstances in life" [14,15].As Tedeschi and Calhoun have shown in their theoretical model of growth, what is important and significant in facing traumatic events and leads to behavioral, emotional, and cognitive reactions in people is the feeling of threat and danger [16].Crises can not only threaten a person's life, but they can also shake a person's imaginary world and destroy a person's basic beliefs.As a result of both situations, the person experiences high emotional distress [17].According to Tedeschi and Calhoun's model, the way to manage the emotional distress caused by the trauma experience is one of the predictors of growth or post-traumatic stress disorder [13].Post-traumatic growth (PTG) is characterized by five areas: (1) increased appreciation for life, (2) more meaningful relationships, (3) increased sense of personal strength, (4) identifying new priorities, and (5) a richer existential and spiritual life [18].According to some studies, PTG can improve the quality of life and boost the psychological state in people who experience traumatic events [17,19].During the COVID-19 pandemic, Kristine Olson and Martin Huecker emphasized the importance of investigating PTG and its facilitators among nurses [20,21].
To address this stark knowledge gap, this systematic review aimed to analyze the predictors and perceived facilitators of PTG in nurses within quantitative, qualitative, and mixed-methods studies.Since the prevalence of PTG has not yet been systematically analyzed in nurses, this study aimed to investigate the problem and identify its effective factors.

Materials and methods
The protocol of this study was registered in PROSPERO under the registration ID CRD42022329671.

Search strategy
A systematic search on studies related to The Prevalence of post traumatic and associated factors among nurses during COVID_19 pandemics, was conducted on Pub-Med, Scopus and ProQuest databases.In addition, the list of review studies on the topic was manually searched to cover all related published articles.The following method was developed using a selection Medical Subject Headings (MeSH) from PubMed: (COVID- The search resulted in 101663 potential related articles on PubMed, Scopus and ProQuest databases.Next, 57 studies remained for full-text screening after removing duplicate records and title and abstract screening.In total, 42 studies were excluded because of unrelated topic, unsuitable design, and inaccessible full-text version.Finally, 15 studies entered in review and meta-analysis process [10,[22][23][24][25][26][27][28][29][30][31][32][33][34][35]. Figure 1 shows the flow diagram of the process of screening and selection. A search strategy was adopted for each electronic database.POLIS (patients, outcome, location, indicator, and study design) was used to select the studies (Table 1).It is one of the most useful models to formulate observational studies regarding evidence combination, ensuring that the question's components are well-defined.

Inclusion and exclusion criteria
The inclusion criterion was all studies examining prevalence of PTG using Post-traumatic Growth Inventory (PTGI).All studies in the selection steps for systematic review and meta-analysis are consisted of three steps namely title, abstract and full text.No limitations based on participant age, sex, ethnicity, language, race, journal language, or publication year were set for inclusion.Studies published in non-English languages were included if they could be translated to English easily using a webbased translation tool.Otherwise, they were excluded from the study.Cross-sectional observational studies were also included.Case studies (case reports or case series), studies with inaccessible full-text, and studies on other target groups were excluded.

Outcome
The main desired outcome of this study was examining the prevalence of PTG in nurses working in hospitals during the COVID-19 pandemic.

Selection of studies and extraction of data
The studies were selected by two independent authors (AA and MB) in all stages including screening, full-text

Qualitative assessment of studies
Two examiners independently used the modified version of the quality assessment checklist for prevalence studies (adapted from Hoy et al.) for cross-sectional prevalence studies.It is a 10-item tool designed for assessing the risk of bias.

Data synthesis
The research data on the prevalence of PTG in nurses were used to perform a meta-analysis by the metaprop command in STATA 12.The results were reported with 95% confidence interval.The I-squared test was used to identify heterogeneity.I 2 < 25%, no heterogeneity; I 2 = 25-50%, medium heterogeneity; I 2 > 50%, high heterogeneity [37].Funnel plot, trim and fill, and Egger's test were used to assess publication bias.A p-value below 0.05 was considered statistically significant.

Included studies
Table 2 shows the features of 15 articles selected from the total of systematically reviewed articles.

Qualitative assessment
Approximately 40% and 46.6% of the studies had low and medium risk of bias, respectively.Two studies had high risk of bias.In the majority of the articles, the participation rate and sampling method were not clearly stated, making them the most notable weaknesses affecting the quality of the assessed studies (Table 3).

PTG prevalence
The desired outcome of this study was examining the prevalence of PTG in nurses during the COVID-19 pandemic.A total of 15 studies entered the meta-analysis and PTG prevalence was randomly calculated [ES 95% Conf.Interval = 0.15[0.12-0.17]).Heterogeneity was reported I2 = 98.52% (P = 0.000), indicating high heterogeneity of the studies (Fig. 2).The studies were eligible for subgroup analysis to reduce heterogeneity.Thus, sub-group were analyzed in terms of types of the quality of the studies; however, severe heterogeneity was still observed (Fig. 2).
Moreover, we categorized the age into two groups.Adulthood is usually classified into three phases: early adulthood or youth (approximately 20-39 years old), middle adulthood (40-59), and old age (60 +) [39].Subgroup analysis based on age category is used to reduce heterogeneity.The Fig. 2C indicates that there is still high heterogeneity.
To assess publication bias in this outcome, funnel plot, trim and fill technique, and Egger's test were used.As demonstrated in Fig. 3, there was no symmetrical dispersion of studies, indicating publication bias.In Egger's diagram, examining the effect of small studies, p = 0.000 was reported and this significant value showed the presence of publication bias.In trim and fill, additional studies up to 21 studies were recommended, and the evidence showed the presence of publication bias.Therefore, the conclusion of this study is highly affected by publication bias (p = 0.000).

Meta-regression
Meta-regression, an approach suggested by Chocrane, was used for nurses' mean age and work experience to examine the effects of potentially influential factors in PTG heterogeneity.As shown in Fig. 3, the results illustrated that with increased work experience and mean age, the mean score of PTGI decreased in nurses.However, the effect was not statistically significant for mean age (P = 0.06).The results indicated that the PTGI score decreased in nurses with more work experience, which was statistically significant (P = 0.04) (Fig. 4).

Discussion
The recent COVID-19 outbreak and its detrimental psychological effects have brought attention to the significance of mental health for COVID-19 frontline nurses.Accordingly, this study aimed to determine the prevalence of PTG in nurses fighting against COVID-19.This meta-analysis revealed a 15 percent PTG prevalence in nurses.
Xiaoli et al. reported The level of PTG across studies ranged from 10 to 77 Percentage in their study [24].In another study by Peng et al., COVID-19 frontline nurses had a moderate level of PTG [29].The COVID-19 pandemic can be considered a new type of collective trauma given its particular characteristics including the global spreading of the virus, impacts on different social aspects, economic issues, advertisement and media, quarantine, and other restrictions [40].Moreover, healthcare staff, especially nurses, suffer from additional concerns such as access to personal protective equipment, fear of infection spread, exposure to COVID-19 in the workplace, and the risk of transmitting the infection to their family members at home [5].Although the      [5,24].As discussed by Tedeschi and Calhoun, some individuals reinterpret their lives through cognitive restructuring because of confronting a trauma or experiencing harm.They consciously regulate their self-perception, interpersonal relationships, and attitude to life.What happens during the growth process is the creation of a new meaning when a harmful event is processed.Managing emotional distress caused by confronting trauma and transforming intrusive rumination to deliberate rumination are influential in creating meaning and changing attitudes [35].The results of a  It should also be noted that this study had high heterogeneity.Causes of high heterogeneity in prevalence metaanalyses can be variable including differences resulting from insufficient sample size and distinct design, studied population, treatments, modifications, statistical analyses, reports, etc. [46].High heterogeneity in this study might have been caused by difference in sample size (presence of studies with comparatively very large sample sizes), demographic differences (women to men ratio), and different reports.
In pandemics, health care workers, particularly nurses, have a vital role in screening and providing care.At the same time, stressful and hard-working conditions can have negative psychological outcomes on nurses.Therefore, adopting strategies to reduce psychological harms caused by confronting the pandemic crises and promoting growth in nurses can not only help their psychological health but also lead to providing better care to patients and others.

Limitations
There were some limitations that should be considered in interpreting the results.Inclusion of cross-sectional studies was one major limitation.This prevented examining growth prevalence in different time periods and the effect of the duration of the pandemic on growth during the COVID-19 pandemic, also some studies had small samples.Except two studies, all examined studies had been conducted in Asian countries.Thus, the results should be generalized to nurses in other regions or countries with caution.Furthermore, a number of studies were removed because of inaccessibility of full information.

Conclusion
This study showed a 15 percent PTG prevalence in frontline nurses during the COVID-19 pandemic.Increased years of work experience and age led to lower PTGI scores in the nurses.According to the results, psychological interventions should be planned for senior nurses with more work experience to reduce harms caused by the pandemic and crisis situation.The interventions should target job burnout and other crucial factors, aiming to train nurses to reflect on their hard work experiences purposefully and constructively and help facilitate their PTG by conversing about the importance of these experiences.

Fig. 1
Fig. 1 Identification of studies from databases and records based on the PRISMA flow diagram[36]

Fig. 2
Fig. 2 Forest plot illustrating for prevalence of PTGI in target population and sub group analysis by quality assessment of studies

Table 1 The POLIS (patients, outcome, location, indicator and study design) POLIS criteria Patients Outcome Location Indicator Study design
Data extraction and qualitative assessment forms, designed in Microsoft Excel in advance, were given to the examiners.The variables were the name of the first author, publication year, study location, design type, sample size, mean age, target audience, work experience, instrument, mean score of developing PTG, PTG assessment outcome, and qualitative assessment score.

Table 2
Features of included studies

Table 3
Quality assessment of included studies in terms of risk of bias